GL173-percutaneous-transcatheter-closure-33340



In January 2018, these codes were moved to Guideline Note 173.CPT 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretationLast reviewed at VbBS in November 2016. Minutes indicate that the staff recommendation was accepted without significant discussion.The following was presented in the meeting materials for the November, 2016 VbBS meeting:33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretationCurrent coding: this procedure is coded with the generic CPT 93799 Unlisted cardiovascular service or procedure Description: placement of a device to reduce the risk of thromboembolism from the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation in patients who are candidates for anticoagulation but who have an appropriate rationale to seek a non-pharmacologic alternative to warfarin. The FDA approved the Watchman device in 2015 for percutaneous left atrial appendage occlusion EvidenceNoelk 2016, systematic review percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation vs oral anticoagulation (OAC)N=20 studies2 RCTs (1,104 patients), 11 observational studies (1,792 patients) of percutaneous LAA occlusion7 studies of surgical LAA occlusionTrials found low-strength evidence that percutaneous LAA exclusion confers similar risks of stroke and mortality as continued OAC, but this evidence was limited to the Watchman device in patients eligible for long-term OAC. Observational studies found moderate-strength evidence of serious harms with a variety of percutaneous LAA procedures. There is low-strength evidence that surgical LAA exclusion does not add significant harm during heart surgery for another indication, but evidence on stroke reduction is insufficient.Conclusions: There is limited evidence that the Watchman device may be noninferior to long-term OAC in selected patients. There is no evidence to recommend percutaneous left atrial appendage exclusion in patients with atrial fibrillation who are ineligible for therapeutic anticoagulation; randomized trials have not been performed.In the few published case series available, the overall risk of serious adverse events with percutaneous device therapy is ≈1 in 15 patients.Surgical left atrial appendage exclusion does not seem to be associated with increased harm when performed during cardiac surgery for another indication, but there is insufficient evidence to compare the efficacy of this procedure to anticoagulation therapy.Singh 2013, economic analysis of left atrial appendage occlusion vs oral anticoagulationCanadian studyWarfarin therapy had the lowest discounted quality-adjusted life years at 4.55, followed by dabigatran at 4.64 and LAA occlusion at 4.68. The average discounted lifetime cost was $21 429 or a patient taking warfarin, $25 760 for a patient taking dabigatran, and $27 003 for LAA occlusion. Compared with warfarin, the incremental cost-effectiveness ratio for LAA occlusion was $41 565. Dabigatran was extendedly dominated.Conclusions—Percutaneous LAA occlusion represents a novel therapy for stroke reduction that is cost-effective compared with warfarin for patients at risk who have nonvalvular atrial fibrillation.Munkholm-Larsen 2012, systematic review percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillationN=14 studies (2,444 patients)Periprocedural mortality and stroke rates were 1.1% and 0.6%, respectively. The incidences of pericardial effusion/ cardiac tamponade and device embolisation were 4% and 0.7%, respectively. At the time of the latest followup (up to 40 months), the overall incidence of stroke among all studies was 1.4% per annum. Existing evidence suggests that PLAAO is a relatively safe treatment for patients with AF. However, there is a need for further evaluation of its efficacy in the form of large and well-designed randomised controlled trials.Other policiesNICE 2010Update 2014: Consider left atrial appendage occlusion (LAAO) if anticoagulation is contraindicated or not tolerated and discuss the benefits and risks of LAAO with the person.Do not offer LAAO (left atrial appendage occlusion) as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated Current evidence suggests that percutaneous occlusion of the left atrial appendage (LAA) is efficacious in reducing the risk of thromboembolic complications associated with non-valvular atrial fibrillation (AF)Percutaneous occlusion of the LAA is a technically challenging procedure which should only be carried out by clinicians with specific training and appropriate experience in the procedure.This procedure should be carried out only in units with on-site cardiac surgeryAmerican College of Cardiology/American Heart Association 2015; study not included due to length, can be viewed here: \The current ACC/American Heart Association/HRS Guideline for the Management of Patients with Atrial Fibrillation does not include recommendations for the use of LAA occlusion devices because of the lack of adequate data and the absence of an FDA-approved LAA closure device labeled for the indication of stroke prevention at the time of their developmentHERC staff summary: percutaneous left atrial appendage occlusion has not been shown to be superior or cost-effective compared to anticoagulation in patients who are eligible for anticoagulation. These devices have not been studied in patients who are not eligible for anticoagulation. There is a high rate of complications with these devicesHERC staff recommendation:Add 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial implant to the Services Recommended for Non-Coverage tableExperimental ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download